I. Introduction

The problem of infertility is of increasing importance both worldwide and in Mexico, where it is estimated that approximately 1.5 million couples have had infertility problems ⁽¹⁾, although only a small percentage of them go to a specialist for seeking treatment, as Zamora (2019) estimates that only between 15-20% of couples in reproductive age with infertility, seek treatment ⁽²⁾.

Regarding infertility rates in the Mexican population, there are two main studies: the National Reproductive Health Survey 2003 of the Mexican Republic analyzed by AS González Cervera, ^[1] who reports that 15% of the women interviewed have experienced at some time, an infertility period of 12 months or more. The second study is the carried out by E. Walker et al. (2010) ^[3], who found a prevalence of 17.5%, and which matches with that of other countries; concluding that infertility is a serious health problem both in Mexico as well as worldwide.

This relevance is not only due to the fact that some couples became aware of their infertility problem, but also to the extraordinary scientific-technological advances that have occurred in recent decades in the field of assisted reproduction and to the awareness of this phenomenon, which has gradually become a major health problem ⁽⁴⁾.

Many couples have faced this situation, and when trying to solve the problem without sufficient premeditation, or with incomplete information, they go through an even greater suffering, due to the long and complex process they are going through. There are cases different and at the same time very similar, where feelings, emotions, illusions and disappointments have been demonstrated by researchers such as Llavona (2008), ⁽⁵⁾ Donati (1993), ⁽⁶⁾ and Moreno Roset 2000) ⁽⁷⁾. In those couples the infertility phenomenon can cause, their moral and religious convictions affected, together with the legitimate desire to have a child, which give a unique intensity to the process they live. The psychological behaviors and consequent physiological reactions indicate that it is an inner experience where these elements constitute an important aspect in the knowledge of the phenomenon ⁽⁸⁾.

These situations are not exempt from the interests that fertility clinics have (economic, marketing, etc.) that usually promotes some misinformation regarding the risks to the mother or the embryo referred to before, during and after the corresponding procedures. Several current studies continue to indicate that the treatments offered by infertility clinics have been built based on specific interests, often linked to monetary flows, which ultimately have an important link with the desire for maternity and paternity ⁽⁹⁾.

The exact dimension of this phenomenon is more understandable with the review of the psychological analysis that evaluates the meaning of infertility for people in this situation. The observations made by Ramírez Morán (2019) ⁽⁸⁾; Álvarez Morales, (2019) ^[9]; Peñarrubia, (2019) ⁽¹⁰⁾ and Moreno-Rosset, (2009) ⁽⁷⁾, in infertile couples, highlight the specific experiences they went through, nuanced with symptoms of emotional disturbances such as anxiety, anguish and melancholy among others.

In this regard, one of the most significant issues, in relation to infertility, refers to the high expectations of success created in the couples when they go to fertility clinics to perform a procedure such as FIVET, ICSI or Artificial Insemination. In recent years, this growing interest in the prediction of a response to a treatment means that users wish to find out about it, although certainly the source of information is not always reliable, namely: social networks, doctors of the same fertility clinics or groups of people with infertility ^{(10) (11)}.

This article tries to highlight the different success rates of Assisted Reproduction Therapies that were obtained in a field investigation carried out in Mexico ⁽⁴⁾, and which are compared to two international reports: the RED LARA, and ESHRE during the period from 2007 to 2010.

II. Methodology

In the first place, reference is made to the methodology of the field study in Mexico, and in the second place to the methodology used for the development of this article. Field study methodology ⁽⁴⁾:

Design. The field study presents a quantitative and qualitative approach and a non-experimental, cross-section, descriptive and correlational design.

Population and study sample. The sample consists of 566 individuals (n = 566) of medium and high economic level ⁽⁴⁾. Of these 125 questionnaires (22.4%) were answered by men and 434 (77.6%) by women. Respondents had an average age of 39.94 for men and 37.37 for women.

It is a non-probabilistic sample, while it is a directed sample, to ensure the representativeness of several entities of the Mexican Republic.

Instrument. The instrument of the field study carried out in Mexico ⁽⁴⁾, was specifically designed for the present investigation and the data were collected through a self-administered questionnaire of 56 closed, dichotomous, frequency and with Likert-type scales.

To confirm the internal consistency and homogeneity of the instrument, a reliability analysis was performed, calculating Cronbach’s alpha coefficient (.498) for Likert reagents. In order to verify its validity, the questionnaire was submitted to the analysis of three experts in the area of Bioethics, Sociology and Philosophy; Recommendations were also received from 23 experts from Italy, Spain and Mexico, some of whom had already conducted field studies using a similar methodology or applying questionnaires to the pilot group to which they were submitted. Based on these previous results, it was concluded that the instrument is reliable.

The data presented in this paper were based on the following questions from that field study:

In these three possibilities, one could answer none. 1, 2 or more than 3 attempts.

Methodology of this article. As already mentioned, this article compares the success rates obtained from four different sources: two international reports and those of infertility clinics in Mexico, and these three are compared with the reported success rates, when applying the questionnaire elaborated in the aforementioned field study ⁽⁴⁾ (Figure 1). Although the information collected cannot be generalized to a broader population, because it is circumstantial, it has a testimonial and legitimate value of those who have infertility, making it possible to explain and dimension the psychological, human, religious and existential part of the problem, whose findings enriched the analysis of the results obtained.

Source. Self-made.

Figure 1 Study design. 

Comparison of Results. Success rates from four different sources:

III. Results

The success percentages reported by the four sources mentioned above are shown. Firstly, the field study in Mexico (A), subsequently reported on websites of assisted fertilization clinics (B), and finally reported by international societies, RED LARA and ESHRE (C).

B. Results published by fertility clinics in Mexico

The field study ^[4] also analyzed a random sample of the information on the websites of Assisted Fertilization Clinics, where they report their success rates. The results are analyzed in Figure 2. Four main types of reports are observed: a) Those that report results in specific and high percentages. b) Those that only mention that they have «very high» chance of success. c) Those that do not mention the success rates, and d)Those that mention real values.

Table 2 Success rates published by fertility clinics in Mexico for Artificial Insemination (AI), as well as for FIVET-ICSI. 

	No. of pregnancies vs. cases	No. of births vs. cases	No. of pregnancies vs. attempts	No. of births vs. attempts
Infertility Clinics in México	FIVET-ICSI 35-90%		IA (10-30)% - (50-90)%

Source. Prepared by the author, based on information on the clinic pages.

Source. See references on the websites of the Assisted Human Reproduction Clinics.

a) Clinics that advertise high percentages of 60%-96% success.

b) Clinics that do not mention a specific percentage, but that create a high expec-tation of success with ambiguous phrases such as «High fertility success rates» (Instituto Vida, 2019), or that offer, «100% Guarantee» (Unit of Reproduction, 2019) or openly false as «Millions of babies… have been born from IVF in Mexico» (CEMPI, 2019).

c) Those that do not mention the issue of success rates.

d) The clinic that announces success rates of 10%-30%, similar to that reportedby international societies.

Figure 2 Analysis of the information of RHA clinics in social networks. We found four types of information depending on the clinics: 

In addition, in most of the clinics’ narratives, they do not offer details about whether these percentages refer to one or several cycles, nor do they refer to the number of embryos transferred per attempt, etcetera.

This imprecise way of providing information is also shown in the following two narratives that correspond to two specialist physicians of the same fertility clinic, who answer in an Internet forum the questions asked about the success rates. The first doctor points out:

«The Intratubal Transfer of Gametes has about 35% chances of pregnancy; in vitro fertilization, an average of 30%; ICSI, approximately 20%. It is logical that sometimes they despair because the treatments are long and uncomfortable. Sometimes one or the other fails, but, over time, statistics have shown that a woman who persists in several attempts... can reach up to 80%.»

The second doctor expresses:

«Young couples with an alteration similar to the one you are presenting have a 40% or greater probability of getting pregnant per cycle, a percentage that has increased thanks to the possibility of freezing embryos not transferred in the initial cycle.»

IV. Discussion

The present study analyzed the experience of a large group of patients who have undergone various treatments in RHA clinics, which was obtained based on a survey previously reported in a doctoral thesis, and compares them against two international reports (that of ESHRE and RED LARA), and the data presented on the websites of fertility clinics in Mexico. These four reports are summarized in Table 4.

The success rates for the case of FIVET/ICSI reported by fertility clinics in Mexico range between 60% and up to 96%. While in our study, the percentage of pregnancies against attempts is (21.9%), which is much more similar to international reports, both from RED LARA (29.4%) and from the ESHRE report (27.3%).

Regarding the success rate, but considering live births against attempts, 10.8% in our report is relatively similar to the RED LARA report rate that is 20.3% and while the ESHRE is 17.7%. These rates seem much more real than the ones reported by fertility clinics of between 60 and up to 96%.

Some publications report higher success rates for Assisted Fertilization (IVF), up to 50%, but only when the couple undergoes several fertilization attempts ⁽¹⁴⁾, in what is called the index of cumulative live births (CLBR for their acronym in English: cumulative live-birth rate); but never the very high levels advertised by some laboratories that frequently mention success rates above 90%.

Summary of success rate for artificial insemination. Table five compares the results of the artificial insemination of our field study ⁽⁴⁾, and what was announced by the RHA clinics of Mexico in social networks.

As for this artificial insemination, there are no data in the international reports (ESHRE and RED LARA) so that no comparison can be made with the data obtained in the present investigation. Therefore, they are only compared with the information on the websites of fertility clinics, where there are also large differences between what was obtained in our study and what was announced by the clinics.

Possible causes of these important differences. Because in Mexico there is no systematic report of the results obtained by fertility clinics, the reports are inconsistent in the promotional pages of these Mexican clinics for different reasons:

The possible percentages of Mexico could be lower than the average of the percentages of the countries that reported to the RED LARA; perhaps something similar to what is observed in the ESHRE report for the countries of Turkey, Italy and Spain that have a lower success rate than the other countries.

Not all clinics where FIVET and/or ICSI in Mexico are performed are registered with RED LARA. It is very likely that the percentages of the centers or establishments that are not accredited by RED LARA, have a lower technology and professionalism and, therefore, their success rates would be even lower. In fertility clinics, as already has been mentioned, there is a tendency to present high success rates to their patients, which are also very different between clinics. In addition, sufficient consistency and adequate professionalism are not observed when presenting these results, since the criteria by which they are governed (age of the woman, number of embryos transferred per cycle, number of cycles, etc.) are so varied, and rarely explained, that its interpretation is not easy and the comparison between them is practically impossible.

It is important to consider that currently the RED LARA reports its results differently: as of 2012, the statistics are shown by countries. On the other hand, the number of cycles increased from 26,646 in 2005 to 85,474 in 2016. As well as the number of reported clinics increased to 178 clinics compared to 130 registered in 2005 throughout Latin America.

Embryo transfer has decreased in women under 24 years by 5.7%. There are also changes in ICSI practice regarding FIVET: 28.3% (FIVET) and 27.4 (ICSI) in 2016 against 21.2 (FIVET) and 20.1 (ICSI) in 2005.

It is well known that the success of assisted reproduction depends largely on the age of the patient and the quality of the ovules; the age with the best result to achieve a delivery after transferring an embryo is 28 years ⁽¹⁴⁾.

Regarding the transfer of embryo, current trends also increasingly recommend the transfer of no more than 2 embryos, as well as low-impact techniques ⁽¹⁵⁾. In these cases, only one egg is used per patient, thus avoiding some of the main problems of in vitro fertilization, such as the accumulation of frozen embryos, multiple pregnancies and ovarian stimulation that carry a high risk of maternal and newborn morbidity and mortality.

On the information that fertility clinics provide on the Internet, there are some changes observed in the marketing used, since success cases are often highlighted in order to positively influence in the emotions of infertile couples, in addition to the considerable increase in promotion in both spectacular ads, radio capsules and social media ads such as Facebook, Twitter, etc.

In Mexico, there is no legal regulation regarding the quality and quantity of information, nor the execution of the techniques presented by the services of fertility clinics.

V. Conclusions

The present work showed that the success rates announced by many RHA clinics on the Web pages are too high, and that it is demonstrated by comparing them against three scientific reports

-the Mexico field study and the RED LARA and ESHRE reports- which shows that these clinics are failing to tell the truth.

Although this lack of veracity on the part of the RHA clinics has been an element that has been previously noted ⁽¹⁶, ¹⁷⁾, this work demonstrates it clearly and reliably.

Sometimes the cause of this lack of veracity seeks to create an optimistic atmosphere around the chances of success, masking failure rates ⁽¹⁶⁾. Although this attempt to create an optimistic atmosphere, could support the patient during their therapy, it has the disadvantage that it is manipulative and on the other hand, it creates false expectations that can later produce more frustration in the patient and even increase the claim when they are not successful. For all the foregoing, it is important to insist that informed consent requires the wide disclosure of all consequences and risks of a medical, social or emotional nature ⁽¹⁶⁾.

The above is part of the information ecosystem that exists around the success rates of fertility clinics in Mexico, although it is not exclusive to our country, since we also observe it in information from RHA clinics also from other countries.

It is important to adjust and delve into the issue because of the importance it represents in today’s society, since the handling of these data must be cautious, real and should even be legally regulated. Especially the psychological vulnerability of patients with infertility problems is another reason to show the urgency of regulating both the issue of information provided by these clinics, as well as aspects of assisted fertilization.

The present work shows the need and advantages -both for patients and for the same health personnel- to offer reliable information to infertile couples, especially since many times patients with infertility problems demand very high results, but this can also be secondary to the excessive expectations created through false information. Therefore, despite the great accusation that this work represents, it is important to show RHA clinics the advantages and the high human and even competitive value that will give them to speak truthfully, providing success rates and informed consent attached to reality.